A psychiatric patient makes threats against his wife. Should the psychiatrist warn her or the police, or should he maintain the confidentiality of the doctor-patient relationship?
Dealing with an ethical quandry such as this -- and many others that arise in medicine, biology and the behavior sciences -- is the purpose of the Institute of Society, Ethics, and the Life Sciences in Hastings-on-Hudson, N.Y., known as the Hastings Center.
Those who think the answers to such dilemmas are fairly clear might want to consider one case study in which participants in a Hastings Center summer workshop for teachers were asked how they would behave in the following situation:
You are a surgeon in a state university hospital. Seven patients require extensive surgery that will succeed only if they are maintained on a newly developed life support system for two weeks. Only one system, however, is available, On what basis do you decide which patient should have the operation?
You might begin narrowing the choice by listing all the factors that might influence your decision -- from medical suitability for the operation, age and life expectancy, marital status and number of dependents, to more value-laden considerations such as intelligence, importance to the community, and the effect on the financial or other-condition of the dependents if the patient died, to such seemingly mercenary concerns as the patient's ability to pay.
In analyzing the cases, the teachers were first directed to choose one patient for the operation without deliberate reference to any ethical theory or principle.
Many refused to make any choice at all, claiming that each patient had a right to live and that no physician should "play God." They suggested instead a lottery, or they proposed that the patients resolve the issue themselves. Others protested that some choice had to be made, for the rights of the patients and their relatives were at stake.
The workshop leader then helped the participants to examine the grounds on which they made their choice -- or non-choice. Did you value importance to the community over other considerations? Did you lean to the patient with the greatest number of dependents? If so, you were limiting damage to "the most vulnerable others" -- an ethical option based on theories of finding the least harmful resolution to a bad situation.
After the initial positions were stated, students were assigned readings which explored theories applicable to the case and their relative merits in life-and-death matters. Class discussions then resumed, and participants were urged to reevaluate their initial choices.
Most of the group, when it came to a final decision, tried to determine which patient had the most vulnerable dependents, regardless of ability to pay or any other consideration. The dependents of one patient were near maturity; those of another, a widow, were young and would be orphaned if the patient died. Two patients were married or divorced, meaning the children would have a surviving parent.
The penultimate choice, then, narrowed to two patients with young children. In the end, most of the participants who felt obliged to make a decision chose to operate on the widow who was the sole guardian of her children.
In terms of ethical theory, this choice amounted to a decision to do the least harm in a bad situation. The teachers rejected the utilitarian values of importance to the community, thus excluding the banker and the cardiac surgeon on the verge of perfecting a new surgical technique. They also ignored a choice which stressed obligation to corporation, institution, or self, which would have meant choosing the patient most able to pay for the operation. Interestingly, medical students, when presented with this case, usually come to the same conclusion.